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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 09/05/2023
Date Signed: 09/05/2023 10:16:21 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20230703100544
FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:SMITH, ANGIEFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:58CENSUS: 20DATE:
09/05/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Angie SmithTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff did not ensure needs were reassessed for resident in care
Facility overcharged resident for care services
INVESTIGATION FINDINGS:
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings from a complaint investigation conducted by the Department. LPA met with Executive Director Angie Smith. Complaint alleges that the facility overcharged a resident for services that they did not require because resident was not reassessed once facility staff observed resident’s care needs. Per review of Physician’s Report dated 7/8/2022, resident was unable to bathe, dress, toilet or groom themselves without assistance, was unable to manage their own medication or cash resources and was bedridden. Review of Admission Agreement Addendum A dated, 7/22/2022 outlines that resident would be charged for a Memory Care room and a level of care II. On 8/1/2022, an updated Addendum A was created, though not signed, indicating that resident would be... Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20230703100544

FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:SMITH, ANGIEFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:58CENSUS: 20DATE:
09/05/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Angie SmithTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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9
Staff did not provide resident with a copy of records in a timely manner
INVESTIGATION FINDINGS:
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings from a complaint investigation conducted by the Department. LPA met with Executive Director Angie Smith. Staff did not provide resident with a copy of records in a timely manner – Complaint alleges that facility did not provide copies of records despite copies being requested via telephone multiple times. LPA confirmed through interview that records were not requested in writing, which is a requirement of regulation. Interview with facility staff on 7/10/2023 revealed that facility was actively working on providing copies via the verbal request.
This agency has investigated the complaint alleging Staff did not provide resident with a copy of records in a timely manner. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.”
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20230703100544
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VINE RIDGE AT CLOVERDALE
FACILITY NUMBER: 496803825
VISIT DATE: 09/05/2023
NARRATIVE
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 in a one bedroom in Assisted Living with a level care B. Per Addendum B of the Admission Agreement, Level Care B is for residents who require supervision/oversight for hygiene, grooming, dressing and bathing in the form of cueing and prompting; laying out clothes. Review of the Tenant Ledger for noted resident shows that resident was charged per the 8/1/2022 Addendum A at move-in. Review of Physician’s Report dated 8/29/2022, reveals that resident is able to bathe, dress, toilet and groom themselves, can manage medications and cash resources and is ambulatory. Per staff interview and review of updated Needs and Services plan, resident was reassessed in November 2022 at resident’s request resulting in their Level of Care being changed to a level A which includes monitoring food liked, dislikes and intake amount but is otherwise independent. Per the Tenant Ledger, resident began being charged for the change in December 1, 2022. It is not clear on the Needs and Services plan if resident was reassessed immediately following the 8/29/2022 Physician’s Report but care level fee was not updated following the report despite resident’s documented care needs changing significantly.
Facility overcharged resident for care services – Based on above and rate discrepancy the resident was overcharged because there is not a documented reassessment immediately following the 8/29/2022 Physician’s Report, which would also initiate a change in care level fee.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.



This report was reviewed with Angie Smith and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20230703100544
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINE RIDGE AT CLOVERDALE
FACILITY NUMBER: 496803825
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
87463(c)
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87463 Reappraisals:(c) The licensee shall arrange a meeting with the resident, the resident’s representative,...when there is significant change in the resident’s condition, or once every 12 months.
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Facility agrees to submit proof that all staff have been trained on regulations 87463 Reappraisals and 87466 Observation of a Resident no later than POC due date 09/29/2023.
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This requirement was not met as evidenced by: Based on record review and interviews, Licensee did not ensure that a documented reassessment was completed following the 8/29/2022 Physician’s Report indicating a significant change in condition. This is a potential risk to the health and safety of residents in care.
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Request Denied
Type B
09/29/2023
Section Cited
CCR
87208(a)
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87208 Plan of Operation:(a) Each facility shall have and maintain a current, written definitive plan of operation. This requirement was not met as evidenced by: Based on record review and interviews,
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Facility agrees to submit self-certification, that all residents will be assessed following a significant change of condition and that assessment will be documented, no later than POC due date 09/29/2023.
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Licensee did not ensure that their plan of operation was followed by changing care level fees to reflect services provided immediately following a resident’s significant change in condition. This is a potential risk to the health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4